Table 1 Scenarios and Debriefing Discussion Topics for the Standardized Patient Encounters

Scenario 1

The student meets the patient for the first time in a 30 min encounter. The patient is already established in the practice, though their physician retired this year. This is their initial visit with the new physician (i.e. the student). The EMR is populated with the patient’s history as well as labs that were completed one week prior to the visit. Last year, the patient’s family physician told her she had “pre-diabetes”, mildly elevated cholesterol, and hypertension. Diet and exercise recommendations were discussed last year. She smokes. Labs done one week ago show hemoglobin A1C 8.1, low-density lipoprotein cholesterol 140. Body Mass Index is 32. Blood pressure is 150/90 and consistent with home measurements.

• Importance of continuity of care

• Establishment of rapport with new patient

• Effective use of the EMR

• Medical management of multiple coexisting chronic diseases (diabetes, hypertension, hyperlipidemia)

• Lifestyle intervention (weight-loss, smoking cessation)

• Appropriate interprofessional referral in management of chronic disease (i.e. diabetes educator, dietician, etc.)

• Appropriate follow-up

• Time management

• Review of the standard progress note to be used as the basis for the next visit

Scenario 2

This is a three-month follow up visit. The patient started lisinopril and metformin after the last visit. Her diabetes control and blood pressure have improved. She met with the diabetes educator and incorporated some dietary changes which have led to modest weight loss. She is still reluctant to take a statin medication due to things she has seen on television, and reports of some family members who developed joint and muscle pain on these medications. She continues to smoke. Today she complains of acute knee pain (consistent with a lateral collateral ligament sprain) and chronic shoulder pain (consistent with rotator cuff tendonitis).

• Acknowledging success in addressing chronic disease

• Negotiating medication recommendations and patient perceptions of potential side effects

• Acute care in the setting of a routine follow-up visit

• Appropriate management of musculoskeletal complaints

• Relationship building and continuity of care

• Review of the standard progress note to be used as the basis for the next visit

Scenario 3

This visit occurs in a simulated hospital room. Patient presents to emergency department with chest pain. Although there is an exertional component to the chest pain, and the patient has risk factors for coronary artery disease, it is also noted that the pain is epigastric. The patient has been taking ibuprofen at an anti-inflammatory dose since the last office visit 6 weeks ago. Students are asked to perform a focused history and physical. When they are ready to order diagnostics or therapeutics, they leave the room and discuss the case with a faculty member. We have prepared results for common diagnostics ordered when a patient with risk factors presents with chest pain (e.g. electrocardiogram, chest x-ray, cardiac enzymes, stress test results, etc.). Once the student orders the diagnostics and therapeutics, they return to the patient room after a simulated elapse of 24 hours. The cardiac work-up is negative of ischemia, and, on further questioning, it appears that the pain may be related to continued use of non-steroidal anti-inflammatories.

• Inpatient care in family medicine

• Assessment of cardiac risk and work-up of acute chest pain

• Differential diagnosis of chest pain

• Review of the discharge summary to be used as the basis for the next visit

Scenario 4

This is a post hospitalization outpatient follow-up visit. Although it was established that the “chest pain” was likely gastritis from non-steroidal use, the episode frightened the patient, and she wants to attempt smoking cessation, and consider a statin medication.

• Hospital follow-up

• Medication reconciliation

• Motivational interviewing (smoking cessation)

• Routine health maintenance and screening

• Overall standardized patient feedback